17. Dizziness/vertigo Flashcards
what are the 4 subtypes of ‘dizziness’?
vertigo, disequilibrium, presyncope and psychological dizziness
causes of vertigo
Peripheral (vestibular) causes of vertigo:
- Benign paroxysmal positional vertigo
- Ménière’s disease
- Vestibular neuronitis
- Labyrinthitis
- Acoustic neuroma
Central causes of vertigo:
- Posterior circulation infarction (stroke), particularly AICA
- Tumour
- Multiple sclerosis
- Vestibular migraine
causes of presyncope
reflex
orthostatic
cardiogenic
causes of disequilibrium
Parkinsons
Diabetes mellitus
causes psychological dizziness
Depression
Anxiety
Hyperventilation syndrome
History taking dizziness/vertigo
PC: room spinning? Lightheaded? Unsteady? Like you’ll faint?
HoPC: speed of onset? Duration? Hearing loss? Tinnitus? Coordination impairment? Change to the way you walk? Associated with nausea? Does it occur with movement of the head? How is your vision? double vision? How is your balance? How is your hearing? Any changes to sensation particularly in you legs and feet?chest pain? exertional?
MHx: diabetes? Heart problems? CVS disease? AF (stroke)?
DHx: drugs that can cause postural hypotension
FHx: parkinsons disease, heart probs-early death
examination dizziness/vertigo
ear - ?infection
UL and LL and CN ?other defecits –> central cause of vertigo
- rombergs ?proprioception or vestibular problem
Cerebellar examination
HINTS examination ?central vs peripheral vertigo
HI – Head Impulse
N – Nystagmus
TS – Test of Skew
Cardiovascular exam to assess for cardiovascular causes of dizziness
symptom onset peripheral vs central vertigo
peripheral = sudden onset
central = gradual onset except stroke
duration of symptoms central vs peripheral vertigo
peripheral = short
central = persistent
hearing loss or tinnitus , more likely in peripheral or central vertogo
peripheral (except BBPV)
coordiantion central vs peripheral vertigo
peripheral = coordination intact
central = coordination impaired
presence of nausea central vs peripherla vertigo
peripheral = more severe
central = mild
what is the HINTS examiantion
The HINTS examination can be used to distinguish between central and peripheral vertigo. It stands for:
HI – Head Impulse
N – Nystagmus
TS – Test of Skew
Head impulse HINTS
pt look at examiners nose
examiner jerks head 10-20 degrees
normal vetsibualr system = eyes stay fixed on examiners nose
In a patient with an abnormally functioning vestibular system (e.g., vestibular neuronitis or labyrinthitis), the eyes will saccade (rapidly move back and forth) as they eventually fix back on the examiner.
The head impulse test helps diagnose a peripheral cause of vertigo but will be normal if the patient has no current symptoms or a central cause of vertigo.
Nystagmus HINTS
Nystagmus can be demonstrated by having the patient look left and right. The eyes rapidly saccade or oscillate, meaning they shake side to side as they try to settle into place.
A few beats can be normal.
Unilateral horizontal nystagmus is more likely to be a peripheral cause.
Bilateral or vertical nystagmus suggests a central cause.
nystagmus central vs peripheral vertigo
Unilateral unidirectional horizontal nystagmus is more likely to be a peripheral cause.
Bilateral or vertical nystagmus suggests a central cause.
test of skew HINTS
alternate cover test
pt fix eyes on examiners nose
examiner covers one eye at a time
normal = eyes remain fixed
central cause = vertical correction when an eye is uncovered (the eye has drifted up or down and needs to move vertically to fix on the nose when uncovered)
elderly ot dizziness on extension of the neck
Vertebrobasilar ischaemia
features BPPV
sudden onset of dizziness and vertigo triggered by changes in head position
each episode typically lasts 10-20 seconds
examination BPPV
positive Dix-Hallpike manoeuvre
management BPPV
responds spontaneously in weeks/months
Epley manoeuvre (successful in around 80% of cases)
teaching the patient exercises they can do themselves at home, termed vestibular rehabilitation, for example Brandt-Daroff exercises
Medication is often prescribed (e.g. Betahistine) but it tends to be of limited value.
features of peripheral causes of vetigo
sudden onset
short duration
hearing loss/tinnitus may be assocoated
coordiantion nromal
severe nausea
Presentation menieres disease
Ménière’s disease often starts as unilateral and progresses to bilateral.
recurrent attacks of:
Hearing loss
Vertigo
Tinnitus
a feeling of fullness in the ear
Unexplained falls (“drop attacks”) without loss of consciousness
Imbalance, which can persist after episodes of vertigo resolve
Spontaneous nystagmus may be seen during an acute attack. This is usually in one direction (unidirectional).
getting worse over time
short episodes –> permenant
not associated with movement
pathophysiology menieres disease
Ménière’s disease is associated with the excessive buildup of endolymph in the labyrinth of the inner ear, causing a higher pressure than normal and disrupting the sensory signals. This increased pressure of the endolymph is called endolymphatic hydrops.
plan ?menieres disease
Plan:
Investigation
1. Refer to ENT for diagnosis (clinical)
+. Audiology to evaluate hearing loss
Management
Acute attacks
1. Prochlorperazine
2. Antihistamines (eg cyclizine, cinnarizine, promethazine)
Prophylaxis:
1. Betahistine (H3 antagonist)
pathophysiology labrythnitis
Labyrinthitis refers to inflammation of the bony labyrinth of the inner ear, including the semicircular canals, vestibule (middle section) and cochlea. The inflammation is usually attributed to a viral upper respiratory tract infection.
presentation labrynthitis
acute attacks of:
Vertigo
may have:
Hearing loss
Tinnitus
following a URTI or more rarely otitis media or meningitis
Patients may have symptoms associated with the causative virus, such as a cough, sore throat and blocked nose.
diagnosis labryntihitis
clinical diagnosis
It is important to exclude a central cause of the vertigo.
The head impulse test can be used to diagnose peripheral causes of vertigo, resulting from problems with the vestibular system (e.g., vestibular neuronitis or labyrinthitis).
management labryntihitis
3 days symptom management
Options for managing symptoms are:
Prochlorperazine
Antihistamines (e.g., cyclizine, cinnarizine and promethazine)
Presentation vestibular neuronitis
Initially, vertigo may be constant, after which it is triggered or worsened by head movement. It is often associated with:
Nausea and vomiting (may be severe)
Balance problems
what is different about labrynthitis and vestibular neuronitis? what is simialr?
labrynthitis has hearing loss and tinnitus, VN doesn’t as it is only the VESTIBULAR nerve involved so no hearing issue
both triggered by infection
management vestibular neuronitis
buccal or intramuscular prochlorperazine is often used to provide rapid relief for severe cases
a short oral course of prochlorperazine, or an antihistamine (cinnarizine, cyclizine, or promethazine) may be used to alleviate less severe cases
How can a diagnosis of MS be made?
Evidence of one episodes with obj results eg MRI w contrast or Oligoclonal bands in CSF
PLUS
evidence of another episode (obj results or a reasonable history)
symptoms MS
visual:
- optic neuritis (vision loss, colour blindness, retro-orbital pain)
- uhthoffs phenomenen
- internuclear opthalmoplegia
sensory:
- pins/needles
- numbness
- trigeminal neuralgia
- Lhermitte’s syndrome: paresthesia in limbs on neck flexion
motor:
- spastic weakness: most commonly seen in the legs
cerebellar
- ataxia
- tremor
other
- urinary incontinence
- sexual dysfunction
- intellectual deterioration
types of MS?
Relapsing-remitting disease
- acute attacks (e.g. last 1-2 months) followed by periods of remission
Secondary progressive disease
- RR then neurological signs and symptoms between relapses
- gait and bladder disorders are generally seen
Primary progressive disease
- progressive deterioration from onset
- more common in older people
pathophysiology MS
Demyelination
Acquired, chronic, immune mediated
LP result MS
Oligoclonal bands in CSF
Invetsigations MS
MRI with contrast
Oligoclonal bands in CSF
management MS
Acute relapse
1st line: oral methylprednisolone 0.5g daily for 5 days
If failed or not tolerated on severe relapse: admission for IV methylprednisolone
Disease modifying drugs such as Natalizumab (a recombinant monoclonal antibody) or Fingolimod
management spasticity MS
1st line: consider baclofen or gabapentin (off label)
What is the scale used in MS to monitor symptoms
Expanded Disability Status Scale (EDSS)
This is based on 8 functional systems:
Pyramidal
Cerebellar
Brainstem
Sensory
Bowel and bladder
Vision
Cerebral
Other
Management bladder dysfunction MS
may take the form of urgency, incontinence, overflow etc
get USS first to assess bladder emptying - anticholinergics may worsen symptoms in some patients
if significant residual volume → intermittent self-catheterisation
if no significant residual volume → anticholinergics may improve urinary frequency
what is a vestibular migraine?
A vestibular migraine, or migrainous vertigo, is a type of migraine that mainly presents with dizziness symptoms. Approximately 40% of people who experience migraines have problems with dizziness and/or balance at some point. This can be before, during, after, or independent of the migraine.
what type of stroke may have vertigo as a feature
Anterior inferior cerebellar artery (lateral pontine syndrome)
Ipsilateral: facial paralysis and deafness {vertigo and vomiting, ipsilateral facial paralysis and deafness }
Pontine = paralysis
presentation acoustic neuroma/Vestibular schwannoma
Cranial nerve V (trigeminal) afferent (corneal) - main one for corneal
Cranial nerve VII (facial) efferent (corneal) and facial palsy
Cranial nerve VIII (vestibulocochlear) vertigo, unilateral sensorineural hearing loss, unilateral tinnitus
what nerves are involved with the corneal reflex
Cranial nerve V (trigeminal) afferent (corneal) - main one for corneal
Cranial nerve VII (facial) efferent (corneal)
association bilateral vestibular schwannoma
neurofibromatosis type 2
plan ?vestibular shwannoma
urgent rf to ENT
MRI of the cerebellopontine angle
Audiometry is also important as only 5% of patients will have a normal audiogram.
Management is with either surgery, radiotherapy or observation.
